Beyond calcineurin inhibitors: emerging agents in kidney transplantation.

PURPOSE OF REVIEW: Despite their effectiveness, calcineurin inhibitors (CNIs) represent a major obstacle in the improvement of long-term graft survival in transplantation. The identification of new agents to implement CNI-free regimens is the focus of current transplant research. The purpose of this review is to summarize the novel immunosuppressive agents, including details about their mechanisms of action, stages of development, potential benefits and challenges. RECENT FINDINGS: Targeting costimulation with belatacept is now an option for controlling the alloimmune response and has proved to be more effective in preserving long-term allograft function than CNIs despite an increased rate of acute rejection in some studies. mTOR inhibitors are also promising with their remarkable antineoplastic properties, though frequent side-effects may limit their broader use. Other agents under development include JAK inhibitors, CD40 blockade and leukocyte adhesion blockers, with unique potential benefits and side-effects in transplantation. SUMMARY: Novel immunosuppressive agents are now available for use in CNI-free regimens in solid organ transplantation. Timing of initiation as well as long-term efficacy and safety are questions that remain to be answered in future clinical trials.

Natural killer cell lysis of cytomegalovirus (CMV)-infected cells correlates with virally induced changes in cell surface lymphocyte function-associated antigen-3 (LFA-3) expression and not with the CMV-induced down-regulation of cell surface class I HLA.

CMV and other viruses down-regulate the cell surface expression of class I HLA, and while this allows them to evade CTL, it may make infected cells more susceptible to lysis by NK cells, due to the failure to engage class I inhibitory receptors on the NK cell. We studied CMV infection and found that fibroblasts infected with virus strains Towne, Toledo, Davis, and C1FE were refractory to NK lysis, while those infected with strains AD169, C1F, or R7 were susceptible. All viral strains down-regulated class I HLA to a similar extent, and we concluded that there was no evidence for any correlation between the latter and susceptibility to NK lysis. In contrast, there was a strong correlation between NK killing of CMV-infected cells and cell surface levels of lymphocyte function-associated antigen-3 (LFA-3). Fibroblasts infected with the Towne, Toledo, Davis, and C1FE strains of CMV down-regulated LFA-3 expression and were refractory to lysis, while strains AD169, C1F, and R7 up-regulated LFA-3 and were susceptible to NK killing. U373 MG (malignant glioma) cells expressed constitutively high levels of LFA-3 and were sensitive to NK lysis when infected with any of the above-listed CMV strains. We estimated that a minimum of between 29,000 and 71,000 LFA-3 molecules per target cell were needed for NK susceptibility. The effects on LFA-3 expression were due to immediate early/early viral gene products. We also demonstrated that fibroblasts infected with the strains Towne, Toledo, Davis, and C1FE expressed a ganciclovir-sensitive late CMV gene product, which delivered an inhibitory signal to NK cells.